Harver Health Insurance Counter Fraud Group: Health Insurers may have Fleeced Taxpayers


(NATIONAL) -- A year-long investigation by the Center for Public Integrity has revealed that health insurers may have fleeced taxpayers out of $70 billion in just five years.

The report is posted on the Center's website by reporter Wendall Potter who says taxpayers should not assume their elected lawmakers in Washington will be outraged or even launching a federal probe about this.


"You would think members of Congress in both parties would be so outraged they’d be launching their own investigation and railing against the “fraud and abuse” they decry on the campaign trail.

But I’m not holding out much hope. That’s because I know just how powerful and influential the health insurance industry is and how its lobbyists almost always get what they want out of Congress and the White House, regardless of who is sitting in the Oval Office."

The Center’s investigation called the "Medicare Advantage Money Grab" found here discovered that:

- Federal officials made nearly $70 billion in “improper” payments to Medicare Advantage plans from 2008 to 2013, mostly over-billings, by manipulating or misusing a Medicare payment tool called a “risk score.”

- From 2007 through 2011, Medicare Advantage risk scores rose more than twice as fast as the average for people in standard Medicare in more than 500 counties nationwide.

- Federal health officials have long kept key financial records of Medicare Advantage plans in a “black box,” inaccessible to the public and press.

- Medicare Advantage health plans collect billions of dollars from controversial “house calls” that industry officials say help improve care but which critics argue inflate costs needlessly.

Reporter Potter says the findings didn't come as a shock to him because during his two decades in the industry, at both Humana and Cigna, "I came to understand just how much of a cash cow the Medicare Advantage program has become to insurers participating in the program. Wall Street financial analysts devote considerable attention to determining how much insurers’ Medicare Advantage business contributes to their bottom lines and how much of the money they take in from the government is actually paid out in medical claims. The less they spend on medical care, the better, from Wall Street’s perspective."

Potter adds this is a huge business and one that is growing rapidly and because the business is so profitable, insurers spend millions of dollars on lobbying, advertising, PR and “grassroots” political activities to keep the money flowing unimpeded.

Harver Health Insurance Counter Fraud Group: Have You Contributed to a Health Scam?


If it works, the GoBe will be life-changing. But it’s a big if.

The GoBe is a bracelet that looks like a small microplane has been affixed to a black watchband—the top of the microplane is a display, and its underside is a sensor. Through its “patented flow technology,” the GoBe promises to measure the wearer’s heart rate, calories burned, sleep, and stress levels. That’s all conceivable, given what the FitBit and other body trackers already measure. But the GoBe also promises something a little more sensational: Automatically tracking the calories of everything the wearer eats, through his or her skin.

“We live in an age where people struggle with their diets and need simple ways to take control of their health,” Artem Shipitsyn, the CEO of GoBe’s parent company, HealBe, says in a video on the device’s Indiegogo campaign page. He says the technology would help “people like me live a healthy life with less effort.”

The automatic calorie-tracking, which GoBe claims to do by reading glucose levels in cells, would revolutionize dieting—even the best calorie-counting apps today rely on manual food logging.

“Tell it nothing. Know everything,” the soothing video narrator’s voice says over b-roll of people skiing and clicking on their smartphones.

The premise was so lofty, in fact, that it didn’t take long for tech reporters, led by PandoDaily’s James Robinson, to attack.

Let’s say GoBe does measure glucose levels without piercing the skin, as it claims to do. That would be a godsend to diabetics, who, as it stands, must regularly prick their fingers to test blood sugar. The less-invasive technology is probably coming soon, Michelle MacDonald, a clinical dietician at the National Jewish Health hospital in Denver, told PandoDaily, “but when it does it will be the size of a shoebox ... It will come from a big lab, will be huge news and make a lot of money.”

But on top of that, blood glucose is only a rough measure of total energy intake. Eat a tablespoon of olive oil, and you’ve consumed 119 calories, but your blood sugar would barely rise. A very thin slice of white bread, meanwhile, would send blood sugar soaring and only yields 40 calories.

From its launch in March, the GoBe campaign steadily raked in Indiegogo donations—it’s now at 1,081 percent of its original $100,000 goal. Robinson stayed on the warpath, citing more and more experts who denounced the GoBe technology and publishing several more articles about what he considers to be a complete scam.

HealBe began commenting negatively on Robinson’s articles, then deleting the comments. GoBe backers started demanding refunds. Delivery of the finished device was pushed back to August.

“I’ve been seeing some disturbing articles regarding this project,” one commenter wrote on the HealBe Indiegogo campaign page. “Various articles stating that the things that the GoBe promises cannot be done ... Can anyone offer a rebuttal? Worried about all of the delays and negative statements. Thanks!” See more…

Harver Health Insurance Counter Fraud Group: Advance directives clarify choices


Pulmonologist Dr. Rick Blevins often sees patients and families grappling with a decision he says should have been made long before.

Blevins treats many patients in the intensive care unit who won't survive. If they do not have advance directives, their families are left to make hard decisions that they may not have answers to.

"It's a subject that comes up and (in the ICU) is the worst possible time for conversations to be initiated," Blevins said.

Many times, the ICU patient is unable to make decisions for himself, so it falls on the family, Blevins said.

The role of the family in that situation is to make the decision the patient would make, Blevins explained. But families don't always know or don't agree.

Advance directives, such as living wills, provide instruction to families and especially health care providers on how the patient wants to be treated in the event of incapacity. Besides the living will, other common forms people complete are powers of attorney for health care that gives another person the authority to make health care decisions in the event of incapacity of the patient, and a form called Five Wishes, which provides not only instructions on medical care but also emotional care.

Blevins said it can be difficult not only for families to have discussions about advance directives, but these conversations may not be happening in the doctor's office either.

Doctors are encouraged to talk to their patients about their health care wishes, but time constraints might prevent that, he said.

Many advance directives are legal documents, so lawyers can help people draw them up. But many are also available on the Internet, and Benefis has a link to the Five Wishes form on its website.

The POLST form, which stands for Provider Orders for Life-Sustaining Treatment, is available for patients who have a serious illness and provides instructions on how they want to be treated in an emergency situation. It can be filled out by a provider only in consult with the patient.

Sue Rose, the State Health Insurance Assistance Program, or SHIP, coordinator for Area VIII Agency on Aging in Cascade County, said she can assist seniors who want to fill out advance directives.

All the services provided are free.

Rose explained that SHIP can provide assistance with Medicare and other health insurance, possible Medicare fraud and long-term care assistance, including advance directives.

While Rose can't offer legal advice, she is able to explain to seniors the purpose of the forms and help them fill the forms out. Work on advance directives is done one-on-one, but Rose gives group presentations periodically.

"We have so many resources to get people connected," said Rose.

Rose said most of the people who come to her for help are aware of what the advance directives do and what they want.

"You also get cold calls where people say, 'I don't know anything. What do I do?'" Rose said.

Eleven agencies on aging exist across the state, and among them all areas of the state are covered. Area VIII covers Cascade County only. All 11 of the agencies have SHIP programs, Rose said.

All these services are free, including notary services, she said.

Blevins encourages people to talk to their doctors and families about advance directives. He also advises people not to wait. Young people need advance directives too, he said, and it is important to make wishes explicitly known.

"People's definitions are different," he said.

Montana has an End-of-Life Registry online that is available through the Department of Justice. The secure database acts as a depository for advance directives. More information is available at https://doj.mt.gov/consumer/end-of-life-registry/.

Blevins also recommends speaking with a lawyer about advance directives, and once they are completed, keeping copies with your lawyer, family, doctor and local hospital.

Harver Health Insurance Counter Fraud Group: Lawmakers Join All-Out Push to Combat Medicare Fraud

WASHINGTON, DC - As law enforcement announced a nationwide sting against Medicare fraudsters today, a bipartisan group of lawmakers in Washington was putting the finishing touches on legislation aimed at making a significant dent in the problem.

Federal law enforcement officials in Miami today announced the details of a multi-agency strike force operation that resulted in the arrest of 90 people nationwide for defrauding Medicare out of some $260 million.

U.S. Senate Special Committee on Aging Chairman Bill Nelson (D-FL) and Ranking Member Susan Collins (R-ME), who have spent a great deal of time examining the problem of Medicare fraud and ways to curtail it, commended the actions announced today by federal officials while also saying that the crackdown illustrates the need to do more to stop Medicare fraud.

Nelson and Collins, along with Sens. Tom Carper (D-DE) and Chuck Grassley(R-IA), have authored legislation to strengthen the government's hand in stopping Medicare fraud. The lawmakers plan to formally file the legislation on Thursday.

"This is exactly why we're doing the legislation," said U.S. Sen. Bill Nelson (D-FL) who chairs the Senate Special Committee on Aging. "We've got to get the problem under control."

Senator Collins added, "For decades, the GAO has identified Medicare as being at high risk for improper payments. This is unacceptable. The loss of these funds not only compromises the financial integrity of the Medicare program, but it also undermines our ability to provide needed health care services to the more than 54 million older and disabled American workers who depend on this vial program. Our legislation emphasizes a strategy to prevent fraud from happening in the first place."

"Medicare provides lifesaving care to some of our nation's most vulnerable citizens," said Sen. Carper. "Unfortunately, too many unscrupulous individuals take advantage of this vital program and end up costing taxpayers millions and shortchanging beneficiaries. It is critical that we do all that we can to curb fraud while protecting beneficiaries and ensuring effective care. This legislation is an important step in combating Medicare fraud and preserving this essential program for the future generations. I commend Sens. Nelson and Collins for their leadership in this effort."
"Our bill will build on the Physician Payments Sunshine Act that I co-authored," Grassley said. "It requires HHS to use available data, including data from the Sunshine Act, to verify doctors' reported information about ownership interests in organizations that bill Medicare. This will help flush out any doctors who commit fraud from their own facilities."

Specifically, the legislation will require Medicare to verify that those wishing to enroll in the program have not owned a company that previously defrauded the government. Currently, Medicare relies on self-reported information. As a consequence, a provider who previously had an ownership interest in an organization that defrauded Medicare could potentially get back into the program by using a different name and failing to disclose their interest in the previous organization.

The bill will also allow private insurers to share information about potentially fraudulent providers with Medicare, and requires new medical coding systems to be tested before they're deployed to ensure Medicare's fraud prevention systems work properly. Additionally, the Medicare Payment Advisory Commission will be allowed to make recommendations regarding fraud prevention and Medicare will be required to develop a strategy to reliably estimate just how many taxpayer dollars are lost each year to fraud.

According to a recent estimate, fraud in the country's Medicare system takes some $60 billion to $90 billion annually out of the system and puts it into the pockets of crooks.

The lawmakers' legislation already has the support of the National Health Care Anti-Fraud Association, the Coalition Against Insurance Fraud, the National Insurance Crime Bureau, America's Health Insurance Plans, Humana and theBlue Cross Blue Shield Association. Continue reading…